About Suicide Screening, Referral, and Imminent Harm in Washington State, 3 units (325)Page 5 of 11

4. Making a Referral

Positive screens result in a referral to a trained behavioral health expert for a comprehensive assessment. This may involve establishing relationships with local behavioral health providers, including crisis centers.

National Action Alliance for Suicide Prevention

Because risk occurs on a continuum, assessment, management, and referrals are different for each situation. Identifying and supporting at-risk individuals, accessing services, and relying on evidence-based care remain key challenges. Simply improving or expanding services does not guarantee that services will be used, nor will it necessarily increase the number of people who follow recommended referrals or treatment (CDC, 2022).

Washington State has a coordinated approach to suicide prevention, with multiple partners and state agencies utilizing guidance from the Action Alliance for Suicide Prevention (AASP). Formed in 2016, AASP is now the coordinated body that informs policy and programmatic change and makes recommendations for the Washington State Suicide Prevention Plan (WSDOH, 2021).

Any provider with an ethical duty to assess patient safety can initiate the referral process; however, the outcome is dependent on providers with the required legal and medical expertise. In extreme circumstances, if a patient is judged to meet the criteria as a “danger to self”, a legal process can be initiated whereby a patient can be held against their wishes in a locked facility for up to 72 hours. During this time a more in-depth medical assessment is completed, and medication management and other safety strategies are initiated.

If a patient indicates an intention to harm themself, a healthcare provider’s next act is to refer the patient to someone who is licensed to decide about an involuntary hold. In larger healthcare organizations, psychiatric services are directly available. Patients who agree to be hospitalized must be placed in the least restrictive environment. Depending on the level of risk, patients can be held against their wishes. Determining whether a patient is safe (and whether they can be held against their will) is left to providers who are legally licensed to make that determination.

4.1 Connecting Patients to Appropriate Referral Resources

Because many people only seek care when they are in crisis, behavioral health systems must provide 24-hour, 7-day a week availability to individuals trained in assessment, supportive counseling, and intervention. Crisis hotlines, online crisis chat/intervention services, self-help tools, crisis outreach teams and other services can ensure that individuals can obtain help when they need it—eliminating barriers related to cost, distance, and stigma.

National Action Alliance for Suicide Prevention

Screenings and referrals are different for each person and each situation. Although often lacking, specialized services are essential—particularly in situations of unique vulnerability, such as suicidal crises. When the risk of suicide and self-harm is acute, services must be offered in a compassionate manner that honors a person’s human dignity (Liljedahl et al., 2017).

4.2 Actions and Referrals by Level of Risk

For a patient who has recently attempted to harm themself, the period after discharge from an emergency department or acute psychiatric ward is a time of high risk. Support services are critical during this time and reductions in suicide deaths have occurred when patients receive timely treatment and referral services (Crane, 2016).

A range of evidence-based interventions exist that have been shown to reduce the risk of suicide. The interventions are most cost-effective when they target high-risk patients. Unfortunately, it is not clear if providers consistently and accurately identify patients at high risk of suicide based on a clinical interview alone (Nock et al., 2022).

4.2.1 High Acute Risk

High Acute Risk At a Glance

Essential Characteristics

  • Suicidal ideation with intent to die by suicide
  • Inability to maintain safety, independent of external support and help

Common Warning Signs

  • A plan for suicide
  • Recent attempt and/or preparatory behaviors
  • Acute Major mental illness
  • Exacerbation of personality disorder


In such cases, direct observation and monitoring is critical before arranging immediate transfer for psychiatric evaluation or hospitalization.

Source: DVA, 2019.

High acute risk for suicidal ideation and behaviors means a patient has serious thoughts of suicide, a plan, a recent suicide attempt, preparatory behaviors, acute major mental illness, or exacerbation of a personality disorder. In such cases, direct observation and monitoring is critical before arranging immediate transfer for psychiatric evaluation or hospitalization (DVA, 2019).

A person with high risk may be in danger of acting on suicidal impulses when they experience some “last straw,” some unbearable insult or burden that seems to make life unlivable. When a person is in this state of mind, external controls may be needed to prevent a suicidal act. Some interventions, such as restricting access to the means of completing a suicidal act may be necessary. This may prevent a fatal act but does not resolve the suicidal impulse or crisis (DVA, 2019).

Transitions in care are particularly high-risk periods. These transitions include the initial diagnosis with a mental condition, initiation of psychotropic medication, discharge from the hospital, and having a recent life-changing event. Identifying who might be at high risk for self-harm or suicide is challenging; clinicians cannot foresee which patients will act upon suicidal thoughts (Balbuena et al., 2022).

A study of nearly 2,000 patients found that prediction of suicide attempts in the 1 month and 6 months after a patient visited an emergency department was significantly improved using machine learning models applied to data from a brief patient self-report scale, especially when supplemented with data from patients’ electronic health records and/or clinicians’ assessments. This study suggests that clinicians can improve their ability to identify patients at high risk of suicide by using data from a brief patient self-report scale and electronic health records (Nock et al., 2022).

4.2.2 Intermediate Acute Risk

Intermediate Acute Risk At a Glance

Essential Characteristics

  • Suicidal ideation and a plan
  • No intent


  • Possible psychiatric hospitalization in some circumstances
  • Intensive outpatient management

Source: DVA, 2019.

Intermediate acute risk includes patients with suicidal ideation and a plan but with no intent. These individuals may present similarly to those at high acute risk and share many of the same features. The only difference may be lack of intent, based upon an identified reason for living (e.g., children), and ability to abide by a safety plan and maintain their own safety. Preparatory behaviors are likely to be absent (DVA, 2019).

Patients at this level of risk should be evaluated by a behavioral health provider and include treatment of co-occurring mental health conditions. Psychiatric hospitalization may be needed if related risk factors are responsive to inpatient treatment (e.g., acute psychosis). Outpatient management of suicidal thoughts or behaviors should be intensive and include frequent contact, regular re-assessment of risk, and a well-designed safety plan (DVA, 2019).

4.2.3 Low Acute Risk

Low Acute Risk At a Glance

Essential Characteristics

  • No current suicidal intent AND
  • No specific and current suicidal plan AND
  • No recent preparatory behaviors AND
  • Collective high confidence (e.g., patient, care provider, family member) in the ability of the patient to independently maintain safety


  • Can be managed in primary care
  • Outpatient mental health treatment in some circumstances

Source: DVA, 2019.

Low acute risk patients are those with recent suicidal ideation who have no current suicidal intent, no current or specific suicidal plan, no recent preparatory behaviors, and high confidence that the patient and family can maintain safety. Individuals may have suicidal ideation, but it will be with little or no intent or specific current plan (DVA, 2019).

If a plan is present, the plan is usually general or vague, without any associated preparatory behaviors (e.g., “I’d shoot myself if things got bad enough, but I don’t have a gun”). These patients are capable of engaging appropriate coping strategies and are willing and able to utilize a safety plan in a crisis (DVA, 2019).

Low acute risk patients can usually be managed in primary care. Outpatient mental health treatment may be indicated, particularly if suicidal ideation and co-occurring conditions exist (DVA, 2019).

4.3 Challenges to Overcome

A gap in all many guidelines is the lack of inclusion of patient-driven safety plans to identify supports, resources, and coping strategies. Another gap in most guidelines is the omission of outpatient intervention safety strategies such as restricting access to lethal means (Harmer et al., 2022).

Continuity of care is a critical part of management and is often lacking. Effective clinical care includes monitoring patients for a suicide attempt after an ED visit or hospitalization and providing outreach, mental health follow-up, therapy, and case management.

Case Example: Daniel Breaks His Sobriety


Dan is a 42-year-old male who was referred to occupational therapy following a motor vehicle accident in which he broke his right femur and left clavicle. He is non-weight bearing on his right leg and is using a wheelchair to get around. Dan is participating in OT to regain strength, for treatment of his left upper extremity, and for assessment of his activities of daily living.

During the subjective evaluation, Dan tells you that after the accident his work truck was impounded, and he lost his driver’s license. He tells you that he was also arrested for driving under the influence. Additionally, he struck another vehicle, and the driver of the other car broke her hip and sustained a severe concussion.

Dan expresses tremendous guilt because another person was injured and remorse for drinking after being sober for more than 2 years. He says he doesn’t know how he’ll be able to pay his bills and is worried about his health insurance. His says that his wife has asked for a divorce and is kicking him out of the house as soon as he is able to walk.

Dan tells you that he feels depressed, hopeless, and angry and finds no pleasure in life. He is unable to work, and despite saying that he loves his 9-year-old daughter, says he wishes he had never impregnated his wife. He says he feels this way every day. He marks a 3 on both PHQ2 screening questions. He tells you “I’m not sure if it’s worth it anymore.”

He tells you he has thought about ending his life in the past but has never acted on this thought. In response to your question, “What stopped you from acting on these thoughts in the past?” He replies, “my daughter—I don’t want to hurt her.”

Screen Results

Your clinic screens all patients for suicide, knowing that injuries and illness increase the risk of depression, which can lead to an increased risk of suicidal ideation and behaviors. Your clinic uses a screening tool called the Patient Health Questionaire-2 (PHQ2). It is clinic policy to repeat this screening at the beginning of each of Dan’s visits.

Your hospital-based clinic has an established protocol for identifying staff responsibilities and procedures for responding to PHQ2 scores. The results are reviewed by the team (primary care provider and behavioral health staff). This is then embedded into the electronic health record as part of the standard care delivery process.

What Action Should You Take?

Because Dan provides a positive answer to both PHQ2 screening questions, you should:

  1. Make an appointment for him the next day to make sure he’s doing okay.
  2. Call social services and ask for a more thorough evaluation.
  3. Reassure him that he’s okay and send him home.
  4. Chart the results of the PHQ2 and continue with your treatment.

Answer: 2


Your role is to screen your patient and determine whether there is a need for immediate referral. You have been to an “in service” that helped you understand the resources available in your area. Because your hospital has mental health services directly available, you make an immediate referral to social services. You assign an aide to sit with Dan in a quiet room until a social worker arrives.

If it was determined that Dan was at immediate risk of harming himself, he could be held against his will. However, only police and mental health workers or providers with specialized training can detain him against his will. Police can hold Dan against his will until a crisis worker arrives and can transport him to a psych facility if needed. Because of Dan’s expressed anger towards his wife, you decide that asking a family member to transport Daniel to the emergency department is not a good idea.

A social worker arrives and escorts Daniel to a quiet room. You follow up later in the day and learn that Daniel has voluntarily admitted himself to the hospital’s inpatient psych unit.